Understandings of self-managed abortion as health inequity, harm reduction and social change.

This commentary explores how self-managed abortion (SMA) has transformed understandings of and discourses on safe abortion and associated health inequities through an intersection of harm reduction, human rights and collective activism. The article examines three primary understandings of the relationship between SMA and safe abortion: first SMA as health inequity, second SMA as harm reduction, and third SMA as social change, including health system innovation and reform. A more dynamic understanding of the relationship between SMA, safe abortion and health inequities can both improve the design of interventions in the field, and more radically reset reform goals for health systems and other state institutions towards the full realisation of sexual and reproductive health and human rights.

It is time to integrate abortion into primary care.

The Roe v Wade decision made safe abortion available but did not change the reality that more than 1 million women face an unwanted pregnancy every year. Forty years after Roe v Wade, the procedure is not accessible to many US women. The politics of abortion have led to a plethora of laws that create enormous barriers to abortion access, particularly for young, rural, and low-income women. Family medicine physicians and advanced practice clinicians are qualified to provide abortion care. To realize the promise of Roe v Wade, first-trimester abortion must be integrated into primary care and public health professionals and advocates must work to remove barriers to the provision of abortion within primary care settings.

Addressing a Crisis in Abortion Access: A Case Study in Advocacy.

As restrictions on abortion increase nationwide, it is critical to ensure ongoing access to abortion care throughout pregnancy. People may seek abortions later in pregnancy as a result of financial or legal barriers that delay care or because of changing circumstances, such as the status of their partner, the health of other children, employment, or a new fetal diagnosis. New York State has been a beacon for abortion access since 1970. Yet, after Roe v Wade was decided, New York State abortion law was not in compliance with federal law, and risk-averse medical institutions hesitated to provide later abortions, forcing patients out of state for care. After years of advocacy, the Reproductive Health Act was passed in 2019. Clinicians and advocates collaborated to translate policy into expanded practice at NYC Health + Hospitals, the largest public health care system in the United States. NYC Health + Hospitals conducted an internal review, identified barriers to abortion care, and addressed these through improvements in public and internal communication, strengthening of procedural skills, and a better referral system. As a result, abortion services have become visible and the system's capacity and gestational age limit have expanded. The example of NYC Health + Hospitals is an instructive model to ensure that abortion care is provided to the most vulnerable patients, including those who need care later in pregnancy. Given the ongoing threat to reproductive rights, this example of expanded access is particularly timely.

The Critical Role of Midwives in Safe Self-Managed Abortion.

As access to legal abortion in the United States becomes more complex, there is increasing interest in self-managed abortion. Choosing to seek abortion care outside the clinical setting can also help people marginalized or harmed by existing health care systems to access needed care in a way that feels safe and empowering. However, patients and midwives alike often have a lack of information about expected outcomes and potential complications that may arise, as well as how to manage these in a health care system that may make appropriate follow-up difficult to access if needed. This article discusses patient education as a harm-reduction approach, and reviews ways that midwives may strategically and ethically participate in this patient education need. As trusted health care providers who are expert in pregnancy and reproductive health, midwives are ideally positioned to meet patient knowledge needs around self-managed abortion.

Implications of the Federal Abortion Ban for Women's Health in the United States.

In 2007, the US Supreme Court upheld the Partial Birth Abortion Ban Act of 2003, also known as the Federal Abortion Ban or "the Ban." The decision undermines decades of established US abortion law that had recognised the preservation of the health of women as a paramount consideration. The Ban asserts that the state's interests in how an abortion is performed and in fetal life override women's rights. It thus further erodes access to safe and legal abortion care. The new law negatively affects evidence-based clinical practice, the training of new providers and clinical innovation. It may also lead to additional legal restrictions on abortion access in the US and has implications for abortion service delivery internationally. Advocates must develop strategies that focus on women's right to control their fertility throughout the trajectory of an unwanted pregnancy.

Putting abortion pills into women's hands: realizing the full potential of medical abortion.

The promise of medical abortion to both reduce maternal mortality and morbidity from unsafe abortion and to expand the reproductive rights of women can only be realized if information and reliable medicines are available to all women, regardless of their location or the restrictions of their legal system. Activist strategies to actualize the full potential of abortion pills are highlighted.

Abortion restrictions in the U.S. military: voices from women deployed overseas.

PURPOSE: U.S. military women and dependents have few options for abortion when facing an unintended pregnancy overseas. Federal law prohibits the use of Department of Defense facilities and funds for abortion except when the woman's life is at risk, and privately funded abortions are permitted at military facilities only if a pregnancy is the result of rape or incest. The purpose of this study was to explore military women's experiences seeking abortion care during overseas deployment. METHODS: We reviewed routine consultation data and user queries from an online service providing information about medication abortion. Information received between September 2005 and December 2009 from U.S. military women and dependents overseas was included. All women gave consent for anonymous use of their data, which were analyzed qualitatively for themes related to experiences seeking abortion. FINDINGS: Data were analyzed for 130 women, including 128 women in the U.S. military and 2 military dependents. Women reported facing numerous challenges accessing abortion overseas, including legal and logistical barriers to care in-country, and real or perceived difficulties accessing abortion elsewhere owing to confidentiality concerns, fear of military reprimand for the pregnancy, and the narrow timeframe for early abortion. With no perceived alternatives, some women considered unsafe methods to terminate the pregnancy themselves. CONCLUSION: U.S. servicewomen overseas lack access to safe abortion services, which may place their health and careers in jeopardy. These women should have the same rights to abortion care as women living in the United States.

Changes in abortion provider practices in response to the Partial-Birth Abortion Ban Act of 2003.

BACKGROUND: The April 2007 Supreme Court Gonzalez v. Gonzalez v. Carhart decision upheld the Partial-Birth Abortion Ban Act of 2003. We conducted a pilot study that measured the impact of the ban in one state with a diverse pool of second-trimester abortion providers. STUDY DESIGN: A survey was administered via telephone to key informants at each facility in Massachusetts where second-trimester abortions are performed in order to assess clinical and administrative changes following the Supreme Court decision. RESULTS: Five hospital-based practices introduced injections to induce fetal demise prior to dilation and evacuation for later second-trimester abortions. One site stopped providing dilation and evacuation abortions in the absence of fetal or maternal indications, and another significantly decreased its volume of procedures. Training opportunities were decreased, and costs at three facilities increased. CONCLUSIONS: The Partial-Birth Abortion Ban Act of 2003 resulted in a range of practice changes in Massachusetts, particularly in hospitals. These changes reflect adherence to legal and policy mandates and not the availability of new scientific evidence. Further study to assess the impact of the ban in states with fewer providers is warranted.

Advanced practice clinicians as abortion providers: current developments in the United States.

A hopeful note in the contemporary abortion environment in the United States is the expanding role of advanced practice clinicians--nurse practitioners, physician assistants and nurse-midwives--in first trimester abortion provision. A large percentage of primary health care in the U.S. is currently provided by these non-physicians but their involvement in abortion care is promising, especially in light of the shortage of physician providers. Two national symposia in 1990 and 1996 approved the expansion of early abortion care to non-physicians. As of January 2004, trained advanced practice clinicians were providing medical, and in some cases, early surgical abortion in 14 states. This has required not only medical training but also political organising to achieve the necessary legal and regulatory changes, state by state, by groups such as Clinicians for Choice and the Abortion Access Project, described here in examples in two states and the reflections of three advanced practice clinicians. Recent surveys in three states show a substantial interest among advanced practice clinicians in abortion training, leading to cautious optimism about the possibility of increased abortion access for women. Most encouraging, advanced practice clinicians, like their physician counterparts, show a level of passionate commitment to the work that is rare elsewhere in health care in the U.S. today.